OMB Form 83-I (Emergency Clearance Request)

MSPB Emergency Clearance Request for Medical and Religious Exception Form 83-I (Signed).pdf

Request for Medical and Religious Exception to the COVID-19 Vaccination Requirement

OMB Form 83-I (Emergency Clearance Request)

OMB: 3124-0016

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PA PERW ORK REDUCTION A CT SUBM ISSION

Please read the instructions before completing this form. For additional forms or assistance in completing this form, contact your agency's Paperwork
Clearance Officer. Send two copies of this form, the collection instrument to be reviewed, the Supporting Statement, and any additional documentation
to: Office of Information and Regulatory Affairs, Office of Management and Budget, Docket Library, Room 10102, 725 17th Street NW,
Washington, DC 20503.
1. Agency/Subagency originating request

2. OM B control nu mbe r

-

a.

U.S. Merit Systems Protection Board (MSPB)

b.

3. Type of information collection (check one)
New collection
a. ✔
Revision of a currently approved collection
b.
c.
Extension, without change, of a currently approved collection
Reinstatement, without change, of a previously approved collection for
d.
which approval has expired
Reinstatement, with change, of a previously approved collection for which
e.
approval has expired
f.
Existing collection in use without an OMB control number

4. Type of review requested (check one)
a.
Regular
1
b. ✔ Em ergency - A pproval reque sted by:
c.
Delegated

3a. Public C omm ents
Has the agency received public comments on this information collection?

6. Requ ested expiration d ate
a.
Three years from approval date

✔

Yes

✔

None

3124

/

10

/

2022

5. Small entities
Will this information collection have a significant economic impact on a
✔ No
Yes
substantial number of small entities?

b.

✔

Other Specify: 06

/

2022

No

7. Title

Request for Medical and Religious Exception to the COVID-19 Vaccination Requirement
8. Agenc y form num ber(s) (if applicable)

N/A
9. Keywords

Executive Orders, Health
10. Abstract

The Request for Medical and Religious Exception to the COVID-19 Vaccination Requirement forms will be used by MSPB to make determinations on
requests by employees or prospective employees to be exempt from the vaccine mandate established by Executive Order 14043 for medical or
religious reasons. MSPB is unable to comply with the normal PRA clearance procedures given the critical role of the collection of information to
meeting our commitments under Executive Order 14043.
11. Affected public (Mark primary with "P" and all others that apply with "X")
a.
b.
c.

P

d.
e.
f.

Individuals or households
Bus iness or othe r for-pro fit
Not-for-profit institutions

F a rm s
Federal Government
State, Local or T ribal Govern men t

13. Annual reporting and recordkeeping hour burden
70
a. Num ber of respond ents
b. Total annual responses
70
1.Percentage of these responses 

collected electronically 
100
c. Total annual hours requested 70
0
d. Current O MB inventory
0
e. Difference
f. Explanation of difference
1. Program change N/A
2. Adjustment
N/A
15. Purpose of information collection
others that apply with "X") 

a.
Application for be nefits
b.
Program evaluation
c. X General purpose statistics
d.
Aud it

%

(M ark prim ary with "P " an d all
e.
f.
g.

P

Program planning or management
Research
Regulatory or compliance

17. Statistical methods
Does this information collection employ statistical methods?
Yes

✔

No

12. Obligation to respond (Mark primary with "P" and all others that apply with "X")
a. P Voluntary
b.
Required to obtain or retain bene fits
c.
Mand atory
14. Annual reporting and recordkeeping cost burden (in thousands of dollars)
a. Total annualized capital/startup costs
b . T o ta l a nn ua l c os ts (O & M ) 

c. Total annualized cost requested 

41,659.80
d. Current O MB inventory
0
e. Difference
0
f. Explanation of difference
N/A
1. Program change
2. Adjustment
N/A

16. Frequency of recordkeeping or reporting (check all that apply) 

a.
b.
Reco rdkeeping
Third party disc losure
c. ✔ Reporting
1. ✔ On occ asion
2.
3.
Wee kly
Mo nthly
4.
Quarterly
5.
Sem i-annually 6.
Ann ually
7.
Biennially
8.
Other (de scribe)
18. Agen cy contact (person who can bes t ans we r qu es tion s reg ard ing the c on ten t of this
submission)
Nam e:

Phone:

D. Fon Muttamara
(202) 254-4772

02/04

OMB 83-I

Reset

19. Certification for Paperwork Reduction Act Submissions
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR
1320.9.

Note:

The text of 5 CFR 1320.9, and the related provisions of 5 CFR 1320.8(b)(3), appear at the end of the instructions.
The certification is to be made with reference to those regulatory provisions as set forth in the instructions.

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a)	 It is necessary for the proper performance of agency functions;
(b)	 It avoids unnecessary duplication;
(c)	 It reduces burden on small entities;
(d)	 It uses plain, coherent, and unambiguous terminology that is understandable to respondents;
(e)	 Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f)	

It indicates the retention period for recordkeeping requirements;

(g)	 It informs respondents of the information called for under 5 CFR 1320.8(b)(3):
(i)	

Why the information is being collected;

(ii)	

Use of information;

(iii)	

Burden estimate;

(iv)	

Nature of response (voluntary, required for a benefit, or mandatory);

(v)	

Nature and extent of confidentiality; and

(vi)	

Need to display currently valid OMB control number;

(h)	 It was developed by an office that has planned and allocated resources for the efficient and effective 

management and use of the information to be collected (see note in Item 19 of the instructions);

(i)	

It uses effective and efficient statistical survey methodology; and

(j)	

It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item below and explain the reason in Item 18 of
the Supporting Statement.

Signature of Senior Official or designee

OMB 83-I	

William Spencer

Digitally signed by William Spencer
Date: 2022.01.06 15:07:55 -05'00'

Date

02/04

Instructions For Completing OMB Form 83-I
Please answer all questions and have the Senior Official or
designee sign the form. These instructions should be used
in conjunction with 5 CFR 1320, which provides information
on coverage, definitions, and other matters of procedure and
interpretation under the Paperwork Reduction Act of 1995.
1. Agency/Subagency originating request
Provide the name of the agency or subagency
originating the request. For most cabinet-level
agencies, a subagency designation is also necessary.
For non-cabinet agencies, the subagency designation is
generally unnecessary.
2. OMB control number
a. If the information collection in this request has
previously received or now has an OMB control or
comment number, enter the number.
b. Check "None" if the information collection in this
request has not previously received an OMB control
number. Enter the four digit agency code for your
agency.
3. Type of information collection (check one)
a. Check "New collection" when the collection has not
previously been used or sponsored by the agency.
b. Check "Revision" when the collection is currently
approved by OMB, and the agency request includes a
material change to the collection instrument,
instructions, its frequency of collection, or the use to
which the information is to be put.
c. Check "Extension" when the collection is currently
approved by OMB, and the agency wishes only to
extend the approval past the current expiration date
without making any material change in the collection
instrument, instructions, frequency of collection, or the
use to which the information is to be put.
d. Check "Reinstatement without change" when the
collection previously had OMB approval, but the
approval has expired or was withdrawn before this
submission was made, and there is no change to the
collection.
e. Check "Reinstatement with change" when the
collection previously had OMB approval, but the
approval has expired or was withdrawn before this
submission was made, and there is change to the
collection.
f. Check "Existing collection in use without OMB control
number" when the collection is currently in use but does
not have a currently valid OMB control number.

5. Small entities

13. Annual reporting and recordkeeping hour burden

Indicate whether this information collection will have a
significant impact on a substantial number of small entities.
A small entity may be (1) a small business which is deemed
to be one that is independently owned and operated and
that is not dominant in its field of operation; (2) a small
organization that is any not-for-profit enterprise that is
independently owned and operated and is not dominant in
its field; or (3) a small government jurisdiction which is a
government of a city, county, town, township, school
district, or special district with a population of less than
50,000.

a. Enter the number of respondents and/or recordkeepers.
If a respondent is also a recordkeeper, report the
respondent only once.

6. Requested expiration date
a. Check "Three years" if the agency requests a three year
approval for the collection.
b. Check "Other" if the agency requests approval for less
than three years. Specify the month and year of the
requested expiration date.

b. Check "Emergency" when the agency is submitting
the request under 5 CFR 1320.13 for emergency
processing and provides the required supporting
material. Provide the date by which the agency
requests approval.
c. Check "Delegated" when the agency is submitting
the collection under the conditions OMB has granted
the agency delegated authority.

b1. Enter the estimated percentage of responses that will
be submitted/collected electronically using magnetic media
(i.e., diskette), electronic mail, or electronic data
interchange. Facsimile is not considered an electronic
submission.
c. Enter the total annual recordkeeping and reporting hour
burden.
d. Enter the burden hours currently approved by OMB for
this collection of information. Enter zero (0) for any new
submission or for any collection whose OMB approval has
expired.

7. Title

e. Enter the difference by subtracting line d from line c.
Record a negative number (d larger than c) within
parentheses.

Provide the official title of the information collection. If an
official title does not exist, provide a description which will
distinguish this collection from others.

f. Explain the difference. The difference in line e must be
accounted for in lines f.1. and f.2.

8. Agency form number(s) (if applicable)
Provide any form number the agency has assigned to this
collection of information. Separate each form number with a
comma.
9. Keywords
Select and list at least two keywords (descriptors) from the
"Federal Register Thesaurus of Indexing Terms" that
describe the subject area(s) of the information collection.
Other terms may be used but should be listed after those
selected from the thesaurus. Separate keywords with
commas. Keywords should not exceed two lines of text.

f.1. "Program change" is the result of deliberate Federal
government action. All new collections and any
subsequent revision of existing collections (e.g., the
addition or deletion of questions) are recorded as program
changes.
f.2. "Adjustment" is a change that is not the result of a
deliberate Federal government action. Changes resulting
from new estimates or action not controllable by the
Federal government are recorded as adjustments.
14. Annual reporting and recordkeeping cost burden
(in thousands of dollars)
The costs identified in this item must exclude the cost of
hour burden identified in Item 13.

10. Abstract

a. Enter the total dollar amount of annualized cost for all
respondents of any associated capital or start-up costs.

Provide a statement, limited to five lines of text, covering
the agency's need for the information, uses to which it will
be put, and a brief description of the respondents.

b. Enter recurring annual dollar amount of cost for all
respondents associated with operating or maintaining
systems or purchasing services.

11. Affected public

c. Enter total (14.a. + 14.b.) annual reporting and
recordkeeping cost burden.

Mark all categories that apply, denoting the primary public
with a "P" and all others that apply with "X."

d. Enter any cost burden currently approved by OMB for
this collection of information. Enter zero (0) if this is the
first submission after October 1, 1995.

12. Obligation to respond

e. Enter the difference by subtracting line d from line c.
Record a negative number (d larger than c) within
parenthesis.

4. Type of review requested (check one)
a. Check "Regular" when the collection is submitted
under 5 CFR 1320.10, 1320.11, or 1320.12 with a
standard 60 day review schedule.

b. Enter the number of responses provided annually. For
recordkeeping as compared to reporting activity, the
number of responses equals the number of recordkeepers.

Mark all categories that apply, denoting the primary
obligation with a "P" and all others that apply with "X."
a. Mark "Voluntary" when the response is entirely
discretionary and has no direct effect on any benefit or
privilege for the respondent.
b. Mark "Required to obtain or retain benefits" when the
response is elective, but is required to obtain or retain a
benefit.
c. Mark "Mandatory" when the respondent must reply or
face civil or criminal sanctions.

f. Explain the difference. The difference in line e must be
accounted for in lines f.1. and f.2.
f.1. "Program change" is the result of deliberate Federal
government action. All new collections and any
subsequent revisions or changes resulting in cost changes
are recorded as program changes.

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f.2. "Adjustment" is a change that is not the result of a
deliberate Federal government action. Changes
resulting from new estimations or actions not
controllable by the Federal government are recorded
as adjustments.
15. Purpose of information collection
Mark all categories that apply, denoting the primary
purpose with a "P" and all others that apply with "X."
a. Mark "Application for benefits" when the purpose is
to participate in, receive, or qualify for a grant, financial
assistance, etc., from a Federal agency or program.
b. Mark "Program evaluation" when the purpose is a
formal assessment, through objective measures and
systematic analysis, of the manner and extent to which
Federal programs achieve their objectives or produce
other significant effects.
c. Mark "General purpose statistics" when the data is
collected chiefly for use by the public or for general
government use without primary reference to the policy
or program operations of the agency collecting the
data.
d. Mark "Audit" when the purpose is to verify the
accuracy of accounts and records.
e. Mark "Program planning or management" when the
purpose relates to progress reporting, financial
reporting and grants management, procurement and
quality control, or other administrative information that
does not fit into any other category.

f. Mark "Research" when the purpose is to further the
course of research, rather than for a specific program
purpose.
g. Mark "Regulatory or compliance" when the
purpose is to measure compliance with laws or
regulations.
16. Frequency of recordkeeping or reporting
Check "Recordkeeping" if the collection of information
explicitly includes a recordkeeping requirement.
Check "Third party disclosure" if a collection of
information includes third-party disclosure
requirements as defined by 1320.3(c).

18. Agency contact

Provide the name and telephone number of the agency 

person best able to answer questions regarding the 

content of this submission.

19. Certification for Paperwork Reduction Act
Submissions
The Senior Official or designee signing this statement
certifies that the collection of information encompassed
by the request complies with 5 CFR 1320.9. Provisions
of this certification that the agency cannot comply with
should be identified here and fully explained in item 18 of
the attached Supporting Statement. NOTE: The Office
that "develops" and "uses" the information to be collected
is the office that "conducts or sponsors" the collection of
information. (See 5 CFR 1320.3(d)).

Check "Reporting" for information collections that
involve reporting and check the frequency of reporting
that is requested or required of a respondent. If the
reporting is on "an event" basis, check "On occasion."
17. Statistical methods
Check "Yes" if the information collection uses
statistical methods such as sampling or imputation.
Generally, check "No" for applications and audits
(unless a random auditing scheme is used). Check
"Yes" for statistical collections, most research
collections, and program evaluations using scientific
methods. For other types of data collection, the use
of sampling, imputation, or other statistical estimation
techniques should dictate the response for this item.
Ensure that supporting documentation is provided in
accordance with Section B of the Supporting
Statement.

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Certification Requirement for Paperwork Reduction Act Submissions
5 CFR 1320.9 reads "As part of the agency submission to OMB of a proposed collection of information, the agency (through
the head of the agency, the Senior Official, or their designee) shall certify (and provide a record supporting such certification)
that the proposed collection of information-­
"(a) is necessary for the proper performance of the functions of the agency, including that the information to be collected
will have practical utility;
"(b) is not unnecessarily duplicative of information otherwise reasonably accessible to the agency;
"(c) reduces to the extent practicable and appropriate the burden on persons who shall provide information to or for the
agency, including with respect to small entities, as defined in the Regulatory Flexibility Act (5 U.S.C. § 601(6)), the use of such
techniques as:
"(1) establishing differing compliance or reporting requirements or timetables that take into account the resources
available to those who are to respond;
"(2) the clarification, consolidation, or simplification of compliance and reporting requirements; or collections of infor­
mation, or any part thereof;
"(3) an exemption from coverage of the collection of information, or any part thereof;
"(d) is written using plain, coherent, and unambiguous terminology and is understandable to those who are to respond;
"(e) is to be implemented in ways consistent and compatible, to the maximum extent practicable, with the existing reporting
and recordkeeping practices of those who are to respond;
"(f) indicates for each recordkeeping requirement the length of time persons are required to maintain the records specified;
"(g) informs potential respondents of the information called for under §1320.8(b)(3); [see below]
"(h) has been developed by an office that has planned and allocated resources for the efficient and effective management and
use of the information to be collected, including the processing of the information in a manner which shall enhance, where
appropriate, the utility of the information to agencies and the public;
"(i) uses effective and efficient statistical survey methodology appropriate to the purpose for which the information is to be
collected; and
"(j) to the maximum extent practicable, uses appropriate information technology to reduce burden and improve data quality,
agency efficiency and responsiveness to the public."
NOTE: 5 CFR 1320.8(b)(3) requires that each collection of information:
"(3) informs and provides reasonable notice to the potential persons to whom the collection of information is addressed of:
"(i) the reasons the information is planned to be and/or has been collected;
"(ii) the way such information is planned to be and/or has been used to further the proper performance of the functions
of the agency;
"(iii) an estimate, to the extent practicable, of the average burden of the collection (together with a request that the
public direct to the agency any comments concerning the accuracy of this burden estimate and any suggestions for reducing
this burden);
"(iv) whether responses to the collection of information are voluntary, require to obtain or retain a benefit (citing
authority) or mandatory (citing authority);
"(v) the nature and extent of confidentiality to be provided, if any (citing authority); and
"(vi) the fact that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number."

10/95


Supporting Statement for Paperwork Reduction Act Submissions
General Instructions
A Supporting Statement, including the text of the notice to
the public required by 5 CFR 1320.5(a)(i)(iv) and its actual
or estimated date of publication in the Federal Register,
must accompany each request for approval of a collection of
information. The Supporting Statement must be prepared in
the format described below, and must contain the
information specified in Section A below. If an item is not
applicable, provide a brief explanation. When Item 17 of the
OMB Form 83-I is checked "Yes", Section B of the
Supporting Statement must be completed. OMB reserves
the right to require the submission of additional information
with respect to any request for approval.

Specific Instructions
A. Justification
1. Explain the circumstances that make the collection of
information necessary. Identify any legal or administrative
requirements that necessitate the collection. Attach a copy
of the appropriate section of each statute and regulation
mandating or authorizing the collection of information.
2. Indicate how, by whom, and for what purpose the
information is to be used. Except for a new collection,
indicate the actual use the agency has made of the
information received from the current collection.
3. Describe whether, and to what extent, the collection of
information involves the use of automated, electronic,
mechanical, or other technological collection techniques or
other forms of information technology, e.g., permitting
electronic submission of responses, and the basis for the
decision for adopting this means of collection. Also describe
any consideration of using information technology to reduce
burden.
4. Describe efforts to identify duplication. Show specifically
why any similar information already available cannot be
used or modified for use for the purposes described in Item
2 above.
5. If the collection of information impacts small businesses
or other small entities (Item 5 of OMB Form 83-I), describe
any methods used to minimize burden.
6. Describe the consequence to Federal program or policy
activities if the collection is not conducted or is conducted
less frequently, as well as any technical or legal obstacles
to reducing burden.
7. Explain any special circumstances that would cause an
information collection to be conducted in a manner:
* requiring respondents to report information to the agency
more often than quarterly;
* requiring respondents to prepare a written response to a
collection of information in fewer than 30 days after receipt
of it;
* requiring respondents to submit more than an original and
two copies of any document;

* requiring respondents to retain records, other than
health, medical, government contract, grant-in-aid, or
tax records, for more than three years;
* in connection with a statistical survey, that is not
designed to produce valid and reliable results that can
be generalized to the universe of study;
* requiring the use of a statistical data classification that
has not been reviewed and approved by OMB;
* that includes a pledge of confidentiality that is not
supported by authority established in statute or
regulation, that is not supported by disclosure and data
security policies that are consistent with the pledge, or
which unnecessarily impedes sharing of data with other
agencies for compatible confidential use; or
* requiring respondents to submit proprietary trade
secrets, or other confidential information unless the
agency can demonstrate that it has instituted
procedures to protect the information's confidentiality to
the extent permitted by law.
8. If applicable, provide a copy and identify the date
and page number of publication in the Federal Register
of the agency's notice, required by 5 CFR 1320.8(d),
soliciting comments on the information collection prior
to submission to OMB. Summarize public comments
received in response to that notice and describe actions
taken by the agency in response to these comments.
Specifically address comments received on cost and
hour burden.
Describe efforts to consult with persons outside the
agency to obtain their views on the availability of data,
frequency of collection, the clarity of instructions and
recordkeeping, disclosure, or reporting format (if any),
and on the data elements to be recorded, disclosed, or
reported.
Consultation with representatives of those from whom
information is to be obtained or those who must
compile records should occur at least once every 3
years - even if the collection of information activity is
the same as in prior periods. There may be
circumstances that may preclude consultation in a
specific situation. These circumstances should be
explained.
9. Explain any decision to provide any payment or gift
to respondents, other than reenumeration of
contractors or grantees.
10. Describe any assurance of confidentiality provided
to respondents and the basis for the assurance in
statute, regulation, or agency policy.
11. Provide additional justification for any questions of a
sensitive nature, such as sexual behavior and attitudes,
religious beliefs, and other matters that are commonly
considered private. This justification should include the
reasons why the agency considers the questions
necessary, the specific uses to be made of the
information, the explanation to be given to persons from
whom the information

is requested, and any steps to be taken to obtain
their consent.
12. Provide estimates of the hour burden of the
collection of information. The statement should:
* Indicate the number of respondents, frequency of
response, annual hour burden, and an explanation of
how the burden was estimated. Unless directed to
do so, agencies should not conduct special surveys
to obtain information on which to base hour burden
estimates. Consultation with a sample (fewer than
10) of potential respondents is desirable. If the hour
burden on respondents is expected to vary widely
because of differences in activity, size, or
complexity, show the range of estimated hour
burden, and explain the reasons for the variance.
Generally, estimates should not include burden
hours for customary and usual business practices.
* If this request for approval covers more than one
form, provide separate hour burden estimates for
each form and aggregate the hour burdens in Item
13 of OMB Form 83-I.
* Provide estimates of annualized cost to
respondents for the hour burdens for collections of
information, identifying and using appropriate wage
rate categories. The cost of contracting out or paying
outside parties for information collection activities
should not be included here. Instead, this cost
should be included in Item 13.
13. Provide an estimate for the total annual cost
burden to respondents or recordkeepers resulting
from the collection of information. (Do not include
the cost of any hour burden shown in Items 12 and
14).
* The cost estimate should be split into two
components: (a) a total capital and start-up cost
component (annualized over its expected useful life)
and (b) a total operation and maintenance and
purchase of services component. The estimates
should take into account costs associated with
generating, maintaining, and disclosing or providing
the information. Include descriptions of methods
used to estimate major cost factors including system
and technology acquisition, expected useful life of
capital equipment, the discount rate(s), and the time
period over which costs will be incurred. Capital and
start-up costs include, among other items,
preparations for collecting information such as
purchasing computers and software; monitoring,
sampling, drilling and testing equipment; and record
storage facilities.
* If cost estimates are expected to vary widely,
agencies should present ranges of cost burdens and
explain the reasons for the variance. The cost of
purchasing or contracting out information collections
services should be a part of this cost burden
estimate. In developing cost burden estimates,
agencies may consult with a sample of respondents
(fewer than 10), utilize the 60-day pre-OMB
submission public comment process and use

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existing economic or regulatory impact analysis
associated with the rulemaking containing the
information collection, as appropriate.
* Generally, estimates should not include
purchases of equipment or services, or portions
thereof, made: (1) prior to October 1, 1995, (2) to
achieve regulatory compliance with requirements
not associated with the information collection, (3)
for reasons other than to provide information or
keep records for the government, or (4) as part of
customary and usual business or private
practices.
14. Provide estimates of annualized costs to the
Federal government. Also, provide a description of
the method used to estimate cost, which should
include quantification of hours, operational
expenses (such as equipment, overhead, printing,
and support staff), and any other expense that
would not have been incurred without this
collection of information. Agencies may also
aggregate cost estimates from Items 12, 13, and
14 in a single table.
15. Explain the reasons for any program changes
or adjustments reported in Items 13 or 14 of the
OMB Form 83-I.
16. For collections of information whose results
will be published, outline plans for tabulation and
publication. Address any complex analytical
techniques that will be used. Provide the time
schedule for the entire project, including beginning
and ending dates of the collection of information,
completion of report, publication dates, and other
actions.

17. If seeking approval to not display the expiration
date for OMB approval of the information collection,
explain the reasons that display would be
inappropriate.
18. Explain each exception to the certification
statement identified in Item 19, "Certification for
Paperwork Reduction Act Submissions," of OMB Form
83-I.
B. Collections of Information Employing
Statistical Methods
The agency should be prepared to justify its decision not to
use statistical methods in any case where such methods
might reduce burden or improve accuracy of results. When
Item 17 on the Form OMB 83-I is checked, "Yes," the
following documentation should be included in the
Supporting Statement to the extend that it applies to the
methods proposed:

1. Describe (including a numerical estimate) the
potential respondent universe and any sampling or
other respondent selection methods to be used. Data
on the number of entities (e.g., establishments, State
and local government units, households, or persons)
in the universe covered by the collection and in the
corresponding sample are to be provided in tabular
form for the universe as a whole and for each of the
strata in the proposed sample. Indicate expected
response rates for the collection as a whole. If the
collection had been conducted previously, include the
actual response rate achieved during the last
collection.

2. Describe the procedures for the collection of information
including:
* Statistical methodology for stratification and sample
selection,
* Estimation procedure,
* Degree of accuracy needed for the purpose described in
the justification,
* Unusual problems requiring specialized sampling
procedures, and
* Any use of periodic (less frequent than annual) data
collection cycles to reduce burden.
3. Describe methods to maximize response rates and to
deal with issues of non-response. The accuracy and
reliability of information collected must be shown to be
adequate for intended uses. For collections based on
sampling, a special justification must be provided for any
collection that will not yield "reliable" data that can be
generalized to the universe studied.
4. Describe any tests of procedures or methods to be
undertaken. Testing is encouraged as an effective means
of refining collections of information to minimize burden and
improve utility. Tests must be approved if they call for
answers to identical questions from 10 or more
respondents. A proposed test or set of test may be
submitted for approval separately or in combination with the
main collection of information.
5. Provide the name and telephone number of individuals
consulted on statistical aspects of the design and the name
of the agency unit, contractor(s), grantee(s), or other
person(s) who will actually collect and/or analyze the
information for the agency.

10/95


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